Coding Challenge: Pharyngitis in Urgent Care

Determine the correct evaluation and management (E/M) service code for this urgent care encounter:

Subjective

Sore Throat: 24-year-old female who complains of a sore throat. Symptoms began 2 days ago. Pain is of moderate severity. Fever is absent. Other associated symptoms have included pain while swallowing, swollen glands, and feeling that her right tonsil is swollen. Fluid intake is good. There has not been contact with an individual with known strep. Current medications include ibuprofen.

Current Outpatient Medications:

  • norethindrone-ethinyl estradiol-ferrous fumarate (LOESTRIN-FE,MICROGESTIN-FE,JUNEL-FE,LARIN-FE) 1-20 MG-MCG per tablet 1 tablet, Oral, Daily
  • OTC Ibuprofen

No Known Allergies

Objective

BP 147/87 (BP Location: Left arm; Patient position: Sitting)  | Pulse 101  | Temp 99.5 °F (37.5 °C) (Tympanic)  | Resp 16  | Ht 5′ 5″ (1.651 m)  | Wt 250 lb (113.4 kg)  | LMP 08/24/2022  | SpO2 99%  | BMI 41.60 kg/m²

  • General appearance: Alert, cooperative and no distress, obese
  • Head: Normocephalic
  • Eyes: PERRLA EOMI
  • Ears: Clear without erythema
  • Nose: Without congestion or drainage
  • Throat: marked erythema, tonsillar hypertrophy, 2+, exudates present and mucous membranes moist
  • Neck: Supple with mild tender bilateral anterior cervical nodes
  • Lungs: clear to auscultation bilaterally
  • Heart: normal, regular rhythm, S1, S2 normal, no murmur, click, rub or gallop
  • Skin: Skin color, texture, turgor normal. No rashes or lesions

Recent Results (from the past 14 hours)

  • POCT CoVid-19 nucleic acid
    • Collection Time: 08/24/22  9:52 AM
    • Negative
  • POCT Strep Nucleic Acid
    • Collection Time: 08/24/22  9:53 AM
    • Positive
  • POCT INFECTIOUS MONONUCLEOSIS ANTIBODY
  • Collection Time: 08/24/22 10:52 AM
  • Negative

Assessment

Strep Pharyngitis, Primary: J02.0

Orders this encounter:

  • POCT CoVid-19 nucleic acid
  • POCT Strep Nucleic Acid
  • POCT INFECTIOUS MONONUCLEOSIS ANTIBODY

Plan:

1.  Discussed diagnosis with patient. Stressed fluid hygiene hydration. Push comfort measures. Follow-up with PCP in 3 to 4 days if not improved or sooner if worsen.

2. Medication changes and new medications: Augmentin 875 mg BID for 10 days. OTC NSAID PRN pain.

3. Follow up in about 1 week, or if symptoms worsen or fail to improve, or with primary care provider.

Let’s consider this patient encounter using this simplified Elements of Medical Decision Making table to find the appropriate LOS (level of service):1

MDM LevelaProblems AddressedComplexity of DataRisk of ComplicationsE/M Service
Codes
Level 2:
Straightforward
Minor/self-limitedMinimal/noneMinimal risk99202
99212
Level 3: Low• 1 stable chronic illness
• 1 acute, uncomplicated illness
• 1 acute, uncomplicated injury
At least 1 of these:
• 2 data sources (eg, ordering or
reviewing tests)
• Independent historian
OTC medication
management
99203
99213
Level 4: Moderate• 1 or more chronic illnesses
with exacerbation
• 2 stable chronic illnesses
• 1 undiagnosed new problem
• 1 acute illness with systemic
symptoms
At least 1 of these:
• 3 data sources (eg, ordering
or reviewing tests); can include
independent historian
• Independent interpretation of
test results
• Discussion of management or
test interpretation
• Prescription drug
management
• Significant social
determinants of health
99204
99214
Level 5: High• Severe illness with
exacerbation
• Threat to life or bodily function
At least 2 of these:
• 3 data sources (eg, ordering
or reviewing tests); can include
independent historian
• Independent interpretation of
test results
• Discussion of management or
test interpretation
Severe without
emergent treatment
99205
99215
aLevel is based on 2 out of 3 elements of medical decision making.
Abbreviations: E/M, evaluation and management; MDM, medical decision making; OTC, over the counter.

Number and Complexity of Problems Addressed

The patient complaint is pharyngitis. This would fall under “1 acute, uncomplicated illness or injury,” which is Level 3.

Amount and/or Complexity of Data to be Reviewed and Analyzed

In this case, the clinician ordered a POCT strep test, a COVID test, and a Monospot. This would qualify as meeting the criteria for Category 1 (ordering of each unique test x 3) in the Moderate section, which is Level 4.

Risk of Complications and/or Morbidity or Mortality of Patient Management

Augmentin was prescribed. Prescription drug management would meet the criteria for Level 4.

2 of the 3 Elements of Medical Decision Making must be met when choosing your level of service. This encounter met Level 4 criteria in 2 of the categories (Data and Risk), so the correct E/M code is 99204.

1American Medical Association. CPT® evaluation and management (E/M) office or other outpatient (99202-99215) and prolonged services (99354, 99355, 99356, 99417) code and guideline changes. Accessed September 10, 2022. Available at: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-codechanges.pdf

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Last Updated on November 16, 2022

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